HospitalInspections.org

The Condition of Participation: Quality Assessment and Performance Improvement Program (QAPI) was out of compliance.

Based on records reviewed and interviews, the Hospital failed to ensure the Quality Assessment and Performance Improvement (QAPI) Program implemented an effective, ongoing, hospital-wide, data-driven quality assessment, and performance improvement program to reduce the prevalence of Hospital Acquired Pressure Injuries (HAPI) in the Hospital.

Cross Reference:
482.21(b)(2)(ii), 482.21(c)(1) & 482.21 (c)(3): Quality Assessment and Performance Improvement: Quality Improvement Activities (283)

Based on observation, record review, and interviews, the Hospital failed to ensure changes that will lead to improvement through data collected were implemented to reduce the prevalence of Hospital Acquired Pressure Injuries (HAPI) in the Hospital.

Findings include:

Review of the Hospital's Performance Improvement Plan Quality and Patient Safety, dated 2024, indicated the following:

- Department managers are responsible for using data assessment findings to evaluate the competence of non-physician employees.

- Performance improvement may be achieved, depending on the complexity of the work process, through individual actions or by means of formal improvement teams.

- Performance improvement initiatives are focused on the aforementioned organizational goals. Performance improvement initiatives are evaluated and prioritized by Quality and Patient Safety Committee (QPSC) and are selected in connection with the Quality and Patient Safety priorities of the Hospital's organization.

-Review of the Hospital Policy titled "Prevention, Management, and Treatment of Pressure Injuries", dated January 2024, indicated the following:
-A complete skin assessment will be performed on arrival to unit.
-Complete a wound assessment for all identified wounds.
-Braden risk assessment will be performed and a risk assessment score determined, score 18 and below indicates risk for skin breakdown.
-Enter Midas report for Hospital Acquired Pressure Injuries (HAPI)

Review of the Hospital's Quality and Patient Safety Council Meeting Minutes indicated the following:
-6/12/2024: Pressure injuries not at target.
-8/19/2024: Pressure ulcers not at target.
-9/16/24: No mention on pressure injuries.
-10/21/24: Increased rates of HAPI
-11/25/24: HAPI remain a concern, nursing education to be done.
-12/23/24: Nursing wound care committee has been meeting and addressing supply issues.

During an interview on 1/13/25 at 9:30 A.M., Wound Nurse #1 said the Hospital had 204 Hospital Acquired Pressure Ulcers (HAPI) for the year of 2024. She said there is a HAPI committee which meets weekly.

Review of the Hospital's HAPI minutes indicated the following:
-11/6/2024: Gaps in care for documentation of wounds on nursing units identified, units do not have necessary supplies for wound care. Review with Chief Financial Officer alternative means for supplies.
-11/29/2024: Assistant Chief Nursing Officer (ACNO) to meet with supply chain and walk units to see where there are a lack of supplies.
-12/6/24: ACNO rounded on nursing units to review supplies, supply chain ordering new bins. Working with finance to get purchase order signed for repair of P500 beds.
-12/12/24 : Clear bins on order.
-1/8/25: Wound care champion luncheon, wound care champions identified. P500 beds being repaired, will get end date from facilities.

During an interview on 1/14/25 at 8:09 A.M., Wound Nurse #1 said there are multiple P500 beds/low air-loss mattresses that have not been repaired, which provide offloading surfaces for patients at risk for skin breakdown. She said a Present on Admission form was created 3 months ago to capture patients' skin issues on presentation to the Hospital's Emergency Department but has been rarely utilized. She said there is one nursing educator for the Hospital and the Educator has been unable to perform competencies and training with nursing staff. She said wound training was not performed with nursing staff in November 2024. HAPIs increased from 25 total in November 2024 to 35 total in December 2024.

On 1/14/25 at 10:54 A.M., the surveyor observed closed inpatient unit 21 in the Hospital. The surveyor observed eight P500 beds that were in need of repair and two Hill-rom bariatric beds in need of repair that were out of use. On inpatient unit the telemetry unit (24 North) the surveyor observed supplies such as aquacell (dressing used for wounds), adaptic (dressing materials), wound gel, and kerlex for wrapping wound dressings were not available in the clean supply room on the unit.

During an interview with the Chief Nursing Officer (CNO) on 1/15/25 at 8:00 A.M., she said the Hospital has been unable to meet the proposed/contracted staffing grids for RN staffing on inpatient units despite offering bonuses for shift pick ups and using contracted travel nursing staff. She said this is due to multiple staff calling out just prior to their shifts, nursing staff leaving the hospital for multiple reasons, and approved leave of absences. She said the pressure ulcer rate in the Hospital has been higher secondary to an increase in reporting of pressure ulcers, some of which reports may be incorrect. She said wound champions were identified to be a resource for other RNs working on the inpatient units. She said the Hospital approved funding to repair the specialty beds but the repairs were not completed yet. She said a second wound RN was hired and trained but the wound RNs' schedules need to be staggered to allow for off shift/weekend coverage if necessary.

The Condition of Participation: Nursing Services was out of compliance.

Based on interviews, documents reviewed, and records reviewed, the Hospital failed to ensure adequate nursing staff were available for the care of all patients in the Hospital, affecting the care of five sampled Patients (#1, #3, #5, #10, and #11) out of a total sample of 21 patients. 1.) Patient #1 did not receive Continuous Veno-venous hemodialysis (CVVHD) for fluid removal as ordered, received Hemodialysis (HD) outside of Hospital policy timeframes, and was not able to receive his/her full HD treatment for fluid removal. 2.) Patient #3 was not monitored by a RN during transport from the Emergency Department to the telemetry unit nor was a nurse-to-nurse hand-off completed as required by Hospital policy upon the Patient's transfer; Patient #3 was discovered to have decreased respirations and low heart rate for an unknown period of time. 3.) Patient #5 was not monitored by nursing staff while ordered for telemetry monitoring (a monitoring system used to continuously monitor a patient's heart rate, rhythm and other vital signs) and was subsequently discovered to be cyanotic (a blue or purple discoloration of the skin due to low levels of oxygen in the blood) with a low heart rate of 39 and unrecordable blood pressure. 4.) Patient #10 was not monitored by nursing staff while ordered for telemetry monitoring and subsequently found to be hypoxic (low oxygen levels) with an oxygen saturation in the 80's and an elevated heart rate of 150. 5.) Patient #11 was admitted to the Hospital and nursing staff did not complete skin and wound assessments and the Patient developed pressure injuries.

Immediate Jeopardy (IJ) was identified on 2/4/2025, regarding the Condition of Participation (CoP) of Nursing Services for failure to ensure adequate numbers of licensed registered nursing staff were available to provide nursing care to meet the needs of patients. Due to a lack of nursing staff and ancillary nursing staff, Hospital nurses were given multiple tasks resulting in patients not receiving monitoring as ordered nor necessary care.

The Hospital was notified of the IJ event on 2/4/25. The Hospital presented a completed Removal Plan to the State Agency on 2/12/25, which was determined to be acceptable. In summary, the IJ event Removal Plan was implemented on 2/12/25. The Hospital's IJ removal plan included changes to the nursing/ancillary nursing staffing process including:
Unit based nursing leaders, in collaboration with nursing supervisors and staffing coordinators, are continually looking forward (at least a week) at schedules and census trends to predicatively staff and proactively fill anticipated needs.
Unit based nursing leaders, in collaboration with nursing supervisors and staffing coordinators, escalate the staffing mitigation plan for identified needs at least 72 hours prior to the start of shift. The mitigation plan includes but is not limited to bonus structure for extra and extended shifts, and overtime for travelers.
Unit based nursing leaders, in collaboration with nursing supervisors and staffing coordinators adjust schedules daily as dictated by nursing unit needs, staff availability and staff competency.
The unit nursing leader will be notified when identified staffing needs have not been filled within 24 hours prior to the start of shift. Nursing unit leaders will work with CNO and ACNO to determine additional mitigation measures to be implemented.
The ACNO/CNO reviews the daily staffing plan approximately two (2) hours prior to the beginning of each shift, in order to anticipate and ensure all staffing needs are met.
In the event of a staffing crisis (i.e. significant nurse callouts, illness, unpredicted weather, etc.), the CNO or designee are notified immediately and will determine the next steps to potentially include requiring all appropriate leaders to come on site in order to mitigate the crisis presented and deploy next steps and resources to ensure safe patient care. An escalation process was created to manage staffing shortages and If a gap was to be identified, all qualified personnel in the organization (i.e. telemetry competent RNs, tele techs, Cath lab staff, would be notified to ask if they would cover the telemetry shift in need of coverage with a bonus structure will be initiated if needed. If unable to fill the gap with qualified staff notification and bonus structure implementation, then the bed manager would cover the gap for telemetry monitoring staff. If the bed manager would be unable to cover the gap, competent nursing leadership would cover the gap in nursing staffing until the need could be filled by nursing staff.
Additionally, the Hospital has immediately opened eight rapid travel nurse positions, increased pay rates for per diem nursing positions, initiated a service level agreement for the hiring of international travel nurses, and has expanded vendor contracts to provide contracted nursing and ancillary nursing staff (including telemetry technicians) while utilizing its corporate contracted staff service as well.

The IJ event regarding the CoP of Nursing Services was removed on 2/12/25, when the State Agency verified direct observations on the affected nursing units, interview with staff, review of all documentation, education attestations, and patient records. The State Agency surveyors observed the inpatient nursing units to confirm nursing staff were immediately available for patients' needs and appropriate monitoring of patients was in place. The surveyors interviewed multiple nursing staff on the inpatient units regarding the scheduling and staffing for the inpatient units. The surveyors reviewed nursing staff schedules/assignments by unit. Education provided to Hospital staff was reviewed by the surveyors and attestations were reviewed to ensure dissemination of education had been performed by the Hospital. Patient records were reviewed by the surveyors on-site to determine if the Hospital was compliant with federal regulation in regard to patient care. Based on the on-site investigation conducted by the surveyors, it was determined that the Hospital's Removal Plan was fully implemented.

Cross Reference:
482.23(b) Standard: Staffing and Delivery of Care (392)
482.23 (b)(6) Standard: Staffing and Delivery of Care (398)

Based on interviews and records reviewed, the Hospital failed to ensure adequate nursing staff was available for the care of three Patients (5, #10, and #11) out of a total sample of 21 patients. 1.) Patient #5 was not monitored by nursing staff while ordered for telemetry monitoring (a monitoring system used to continuously monitor a patient's heart rate, rhythm and other vital signs) and was subsequently discovered to be cyanotic (a blue or purple discoloration of the skin due to low levels of oxygen in the blood) with a low heart rate of 39 and unrecordable blood pressure. 2.) Patient #10 was not monitored by nursing staff while ordered for telemetry monitoring and subsequently found to be hypoxic (low oxygen levels) with an oxygen saturation in the 80's and an elevated heart rate of 150. 3.) Patient #11 was admitted to the Hospital and nursing staff did not complete skin and wound assessments and the Patient developed pressure injuries.

Findings included:

Review of the Hospital policy titled "SVH ADM CLN 8.6.8 Cardiac Monitoring- Inpatient Critical and Acute Care", reviewed 4/8/21, indicated the following:

-Cardiac monitoring refers to both hard wired monitoring capability and wireless ambulatory capability. Telemetry monitoring refers to a form of cardiac monitoring using a wireless transmitter for ambulatory monitoring.

-Cardiac monitoring is available on selected patient care units throughout the hospital by physician/provider order.

-Default alarm settings: Red Alarm (default with sound alert):
1) Asystole (a cardiac arrest rhythm where the heart's electrical and mechanical activity stops completely) >4 seconds
2) Ventricular Fibrillation/ Ventricular Tachycardia
3) Ventricular Tachycardia >100 beats/ minute
4) Premature ventricular contractions (PVCs) Extreme Tachycardia >140 beats/ minute
5) Extreme Brady (bradycardia- a cardiac arrhythmia where your heart rate is below the averages) <40 beats/min.
Event Definitions
1. Life Threatening:
Extreme Brady (Heart rate less than the extreme brady limit <40 beats/ min)
-All patients on cardiac monitoring are transported without a monitor unless determined by a physician/provider.
-All critical care patients (ICU, PCU, Cath Lab, ED, PACU) are monitored during transport

-Nursing Responsibilities:
-Handoff of patients includes a review of alarm settings and rhythm.
-The Registered Nurse (RN) will notify the physician/ provider of any significant alarm conditions (i.e life threatening or deviation from baseline).
- At a minimum, notify the physician/ provider for Bradycardia (rate <40) unless baseline.
-Rhythm strips will reflect a 6 second time duration and be mounted onto the monitor strip form upon admission, every shift and with rhythm/rate/condition changes.
- Rhythm strips will be printed: on admission, every shift, with any new dysrhythmia, with any cardiac-related discomfort or change in condition.

Review of the Hospital Policy titled "Safety Event Management" effective 12/3/21, indicated the following:

Purpose- support a culture of shared accountability for the identification, reporting and management of safety events that may impact the quality of care provided at facilities.

Definitions-

Event Report: A confidential, internal submission used for reporting of patient safety issues and performance improvement initiatives.

Patient Safety Event Reporting System (ERS): The mechanism for a Facility staff member to complete an Event Report for patient safety events or near misses.

Root Cause Analysis (RCA): A process for identifying the base or contributing causal factors that underlie variations in performance associated with SSE, SE or Near Misses.

Safety Event: Any event that leads to or is the precursor to a potential or actual negative patient outcome including a near miss, SSE, or SE

Sentinel Event (SE)- patient safety event not primarily related to the natural course of illness or underlying condition that reaches a patient and results in death, severe harm, or permanent harm.

Serious Safety Events (SSE)- Never events

Policy: Staff members who discover or who have direct involvement in and/or knowledge of a safety event must complete an Event Reports using the Facility ' s ERS. Any possible SSE and SE

1.) Patient #5 presented to the Hospital Emergency Department (ED) on 12/2/24 via ambulance with altered mental status and a past medical history significant for Chronic Obstructive Pulmonary Disease, high blood pressure, and chronic kidney disease.

Review of Patient #5's medical record indicated he/she was initially hemodynamically stable upon presentation to the Emergency Department (ED), however, he/she soon needed 15 liters/min of oxygen (O2) via a non-rebreather mask (a device that delivers oxygen to patients) to maintain an oxygen saturation of 88%. A chest x-ray performed in the ED indicated findings of congestive heart failure (a condition in which the heart doesn't pump blood efficiently), asymmetrical pulmonary edema (a buildup of fluid in the lungs), and bilateral pleural effusion (buildup of fluid between the tissues that line the lungs and the chest). Patient #5 was ultimately transferred to the Intensive Care Unit (ICU) from the ED for further management. On 12/3/24 at 2:27 A.M. physician orders were entered for Continuous Cardiac Monitoring with special instructions to maintain telemetry while off the unit for Patient #5 and on 12/5/24 at 9:49 A.M., Telemetry Class I orders were entered for the Patient. On 12/5/24 Patient #5 was transferred from the ICU to an inpatient telemetry unit.

Review of Nursing Narrative Note dated 12/6/24 at 9:12 A.M. indicated that the Certified Wound and Ostomy Care Nurse entered Patient #5's room, along with Registered Nurse (RN)# 5 and found Patient #5 to be cyanotic with agonal breaths (a brainstem reflex that occurs when the brain isn't receiving enough oxygen), his/her BP was not recordable, and he/she had a heart rate of 39. The Note further indicated a Code was called and physicians and the Code Team responded at the bedside.

Review of Rapid Assessment Team Record dated 12/6/24 at 9:41 A.M. indicated the Rapid Assessment team was activated on 12/6/24 at 9:01 A.M, arrived at 9:05 A.M., and reason for activation was Patient #5's respiratory rate was 2 breaths/minute (the normal range is 12-20 breaths/ minute), new onset difficulty breathing, O2 saturation decreased from baseline, change in skin color (pale, dusky, gray, blue), a heart rate oof 38 with a cardiac rhythm showing sinus bradycardia (low heart rate) and change in mental status.

Review of Patient #5's Discharge Summary dated 12/6/24 at 2:11 P.M. indicated that after a rapid response was called for Patient #5 due to unresponsiveness, the Patient's healthcare proxy (a person designated to make healthcare decisions) decided to make Patient #5 Comfort Measures Only (CMO). Patient #5 was extubated and expired on 12/6/24 at 10:47 A.M.

Review of the Staffing Schedule on 12/6/24 indicated that the Charge Registered Nurse assigned for the 7:00 A.M.- 7:00 P.M. was also assigned to the unit's Telemetry Monitoring.

During an interview on 1/13/25 at 9:25 A.M., the Certified Wound and Ostomy Nurse said she entered Patient #5's room with Registered Nurse (RN) #5 to assess his/her wound when Patient #5 was found cyanotic (having a bluish or purplish discoloration of the skin, lips, or mucous membranes) with agonal breathing.

During an interview on 1/13/25 at 11:27 A.M., RN #5 said she was assigned the care of Patient #5 on 12/6/24 and was also orienting a new graduate nurse. RN # 5 indicated that Patient #5 was ordered for telemetry monitoring. RN #5 said on this day there was not a dedicated staff member to monitor the telemetry monitors. RN #5 said she accompanied the Wound Nurse to assess Patient #5's pressure injury and found Patient #5 with agonal breathing and heart rate in the 30's. RN #5 said the overnight shift made the staffing office aware that there were no staff available to monitor telemetry on the day shift. RN#5 said she did not report this incident via the Hospitals internal event reporting system.

During an interview on 1/14/25 at 3:08 P.M., RN #6 indicated that she was assigned as charge nurse on 12/6/24 as well as tasked with monitoring the telemetry monitors for the unit. She said the charge nurse is tasked with carrying a beeper that alerts the charge nurse to admissions and discharges for the unit, and the charge nurse will assist other nurses on the unit. RN #6 said most times the charge nurse also has a full patient assignment on top of these other tasks. RN #6 said that the charge nurse may also be assigned for telemetry monitoring for the unit. Registered Nurse #6 said she did not have a patient assignment 12/6/24. Registered Nurse #6 said although she was tasked with telemetry monitoring on 12/6/24 she was not able to monitor the telemetry at all times as the day was busy and she was helping out on the floor with other patients, printing documents for new admissions and taking patients for testing off the unit if required. RN #6 said if a patient's heart rate was in the 30's the Telemetry monitor would alarm, and the expectation would be that staff would check on the patient. She said any nurse can respond to the telemetry alarm and then notify the patient's primary nurse. RN#6 said on this day she doesn't remember an alarm and or a rapid response/code being called for Patient #5. Registered Nurse #6 said it is not uncommon to have a full patient assignment, be tasked with charge RN as well as monitoring telemetry. She said when this occurs all the nurses know to monitor their own telemetry patients.

During an interview on 1/14/25 at 2:20 P.M., the Director of Nurses for the second floor indicated that on 12/6/24, the Charge Nurse was assigned as the telemetry monitor. The Director further said the expectation would be that the telemetry nurse would have notified the Patient's nurse of changes or responded to the Patient's alarm. The Director said when there is no telemetry nurse or tech assigned to monitor the telemetry patients, she will try and fill the role but is not able to sit there constantly. The Director said she couldn't remember if staff reported this event to her and said she was unaware of the event.

During an interview on 1/14/25 at 10:55 A.M., the Director of Critical Care, Cardiac Telemetry and Wound Care said the expectation of the staff member tasked with monitoring Telemetry is that they have no other responsibilities. She said it's the expectation that staff put in event reports for events like these for Risk Management and managers to review and said she was unsure if a report had been completed for this event in which Patient #5 was ordered for continuous telemetry monitoring and was found hypoxic and bradycardic.

During an interview on 1/15/25 at 8:00 A.M., the Risk Manager said there was no incident report put in via the Hospitals internal event reporting system on Patient #5's event on 12/6/24.

During an interview on 1/15/25 at 8:16 A.M., the Chief Nursing Officer (CNO) said the Hospital has not been able to meet the staffing grid for nurses, but the expectation is that the staff doesn't deviate from the telemetry plan, which involves having dedicated staff to monitor telemetry patients. The CNO said there was no incident report put in on Patient #5 and was unaware of Patient #5's event. The CNO said the Hospital is in the process of purchasing a new centralized telemetry system that will be staffed with telemetry technicians to monitor the telemetry system Hospital wide.


40928

2) For Patient #10, the Hospital failed to ensure that he/she was monitored while on telemetry as ordered. Subsequently, Patient #10 was found to be hypoxic (low oxygen levels) with oxygen saturation in the 80's and tachycardic with heart rate to 150 (normal adult range is 60-100 beats/min).

Review of Patient #10's medical records indicated that he/she presented to the Emergency Department (ED) on 12/19/24 with increased secretions from his/her tracheostomy (a tube inserted through an opening in the neck and into the windpipe to allow air to flow into the lungs) requiring suctioning every three to four hours. Patient #10 has a history of traumatic brain injury, subarachnoid hemorrhage status post craniectomy with resultant tracheostomy, Hypertension and Atrial Fibrillation (AFib-a quivering or irregular heartbeat, or arrythmia).

Review of the Progress Note documented by the Attending Physician, dated 12/23/24 at 1:26 P.M., indicated that a Rapid Response (a system where a team of providers is summoned to the bedside when a patient is showing signs of clinical deterioration) was called on 12/23/24 at approximately 10:30 A.M. for Patient #10. The note further indicated that Patient #10 was found to be hypoxic (low oxygen levels) with oxygen saturation in the 80's and tachycardic heart rate to 150. The note indicated Patient #10 was suctioned with minimal improvement and admitted to the Progressive Care Unit (PCU).

Review of the Nursing Note documented by Progressive Care Unit (PCU) Registered Nurse (RN), dated 12/23/24 at 1:51 P.M., indicated that Patient #10 was brought to the PCU as a Rapid Response for difficulty breathing/occluded airway. The note indicated that Patient #10 was tachycardic, with a heart rate in the 160's and reported to have A-fib with RVR (rapid ventricular response) (a type of irregular heart rhythm that can lead to serious complications; when the atria of the heart contracts rapidly, causing the ventricles to beat to quickly).

Review of Patient #10's medical record indicated that there was a physician order for telemetry monitoring Class I (72 hours) placed on 12/21/24 at 11:05 A.M.

Review of the Staffing Schedule for 12/23/24 indicated no assigned telemetry monitor for the 7A.M. to 7 P.M. shift.

During an interview on 1/13/25 at 9:25 A.M., the Certified Wound and Ostomy Nurse said she entered Patient #10's room for a wound consult and found him/her in respiratory distress. She said a Rapid Response was initiated.

During an interview on 1/14/25 at 11:30 A.M., Registered Nurse (RN) # 7 said she was assigned Patient #10 on 12/23/24. She indicated that this was her first day off orientation. RN #7 said Patient #10 was on telemetry monitoring, but they did not have a staff member to monitor Telemetry that shift, and the monitor at the end of the unit wasn't working RN#7 said she checked Patient #10 after getting report and that he/she appeared to be doing well and RN #7 didn't feel they required suctioning. RN#7 said she asked another nurse to show her later how to suction a trach because she had never done it in practice. RN #7 said the Wound Care Nurse was in with Patient #10 and at this time she called out that Patient #10 was struggling and to get suction. RN #7 said another nurse on the unit responded with suction and a Rapid Response was called. RN #7 was unable to say if she had reported this incident via the Hospitals internal event reporting system.

During an interview on 1/14/25 at 2:20 P.M., the Director of Nurses for the second floor indicated that on 12/23/24 the day shift had a call out resulting in Patient #10's unit having no staff to monitor telemetry.

During an interview on 1/14/25 at 10:55 A.M., the Director of Critical Care, Cardiac Telemetry and Wound Care said the expectation of the staff member tasked with monitoring telemetry is that they have no other responsibilities. The Director acknowledged there was no telemetry monitor assigned to Patient #10's unit on 12/23/24 day shift. The Director said it's the expectation that staff put in event reports for events like these for Risk Management and managers to review and was unsure if a report had ever been put in.

During an interview on 1/15/25 at 8:00 A.M., the Risk Manager said there was no incident report put in via the Hospitals internal event reporting system on Patient #10's event on 12/23/24.

During an interview on 1/15/25 at 8:16 A.M., the Chief Nursing Officer (CNO) said the Hospital has not been able to meet the staffing grid for nurses, but the expectation is that the staff doesn't deviate from the telemetry plan, which involves having dedicated staff to monitor telemetry patients. The CNO said there was no incident report put in on Patient #10 and was unaware of Patient #10's event. The CNO said the Hospital is in the process of purchasing a new centralized telemetry system that will be staffed with telemetry technicians to monitor the telemetry system Hospital wide.

The Hospital failed to ensure 2 Patients (Patient #5 and #10) out of a total sample of 12 patients were monitored while on ordered telemetry monitoring and subsequently, the Hospital failed to ensure this event was reported by staff and investigated per Hospital policy.



41143

3.) Review of the Hospital Policy titled "Prevention, Management, and Treatment of Pressure Injuries", dated January 2024, indicated the following:
-A complete skin assessment will be performed on arrival to unit.
-Complete a wound assessment for all identified wounds.
-Braden risk assessment will be performed and a risk assessment score determined, score 18 and below indicates risk for skin breakdown.
-The Braden Risk Score will be assessed and documented each shift, with change in primary nurse, with significant change in patient's condition, and with transfer to higher level of care.
-Wound photographs will be taken of each wound upon admission to unit, at time of discovery, weekly, and at discharge.
-Interventions for identified skin integrity issues:
-Notify physician
-Initiate initial wound care consult
-The staff Registered Nurse (RN) is responsible for implementation and following wound care RN plan of care.
-Enter Midas report for Hospital Acquired Pressure Injuries (HAPI)

Patient #11 was admitted to the Hospital on 12/7/24 from a transferring hospital with altered mental status and required continuous EEG (Electoencephalography, a test that measures electrical activity in the brain) monitoring.

Review of Patient #11's medical record indicated the Patient was evaluated by a physician on 12/7/24 at 10:12 P.M. Patient #1's physician note dated 12/7/24 indicated the Patient had not had anything to eat for an unclear number of days, was frail, had impaired mobility, and had a sacral wound. An order for a wound care consult was written in Patient #1's Electronic Medical Record (EMR) on 12/7/24 at 11:48 P.M. for a sacral wound. Patient #1 arrived to the telemetry unit on 12/8/24 at 12:03 A.M. Patient #1 was assessed by an RN on 12/8/24 at 3:00 A.M., to have a Braden score of 11 (risk for skin breakdown) with consult recommendation for a wound consult and to apply protective dressing and initiate turning for pressure reduction; no skin assessment details or wound assessment details were documented during that RN assessment. On 12/8/24 at 4:13 P.M., a physician evaluated Patient #11 to have stage I heel ulcer and a sacral decubitus ulcer and required a wound care consult. On 12/9/24 at 12:41 A.M., a wound consult was ordered for Patient #1 bilateral heel and sacral ulcers. On 12/9/24 at 2:02 A.M. Patient #11 was assessed by a RN to have a lower Braden score of 8, with no documented skin assessment details or wound assessment details. On 12/9/24 at 1:16 P.M., Patient #11 was evaluated by a physician to have bilateral heel ulceration with sacral wounds with a plan for a wound care consultation. Patient #11 was transferred to the ICU on 12/9/24 at 7:18 P.M. On 12/9/24 at 7:48 P.M. Patient #11 was assessed by a RN to have a Braden score of 9 with sloughing (dead tissue) at the Patient's lower right heel and skin abnormality at his/her coccyx; dressings were applied to both areas. On 12/10/24 at 7:52 A.M. a wound consultation was ordered for Patient #11 for sacral and heel pressure wounds.

Patient #11 was assessed by the Wound RN on 12/10/24 at 9:20 A.M. The Wound RN #1 assessed Patient #11 to have unstageable pressure injuries to his/her coccyx/right heel. Patient #1 was assessed to have an unstageable coccyx pressure injury measuring 8cm (centimeters) x 5 cm covered in slough and an unstageable right heel pressure injury measuring 5.5cm x 5.2 cm covered in 50% eschar (black, dead tissue). Recommendations were made by Wound Nurse #1 for dressings to Patient #1's pressure injuries, offloading interventions including low air-loss mattress, offloading heel boots and cushion, low head of bed, reposition every two hours, and a dietary consultation.

Further review of Patient #11's medical record failed to indicate any orders for wound treatment prior to 12/10/24 nor any wound measurements, RN skin assessments, nor wound pictures on admission to the telemetry unit on 12/8/24.

Review of the telemetry unit schedule (24 North) for day shift on 12/8/24 indicated a census of 23 patients on the unit with five RNs on the schedule (four with patient assignments and one monitoring the telemetry system) and two Patient Care Assistants (PCA).

Review of the telemetry unit schedule for day shift on 12/9/24 indicated a census of 23 patients on the unit with four RNs on the schedule and two PCAs.

Review of the Hospital's proposed staffing guidelines for the telemetry unit indicated a total patient census of 23 patients would require seven RNs and three PCAs to be staffed during the day shift.

During an interview on 1/13/25 at 9:30 A.M., Wound RN #1 said pressure ulcers/injuries have been occurring at the Hospital, many of which are preventable. She said staffing ratios for RNs working on the inpatient units have been too high and interventions such as repositioning and incontinence care are not happening. She said often supplies are not well stocked on the inpatient units and nursing staff need to look for supplies from other inpatient units. She said minor pressure injuries are developing into stage 4 pressure injuries while patients are inpatient in the Hospital. She said there are not enough cameras on the inpatient units for capturing pictures of wounds for monitoring of patients' wounds.

During an interview with RN #6 on 1/14/25 at 3:15 P.M., she said wound care on the telemetry unit has been challenging as there have been patients with multiple wounds on the unit at once with challenging staffing. She said often the charge or resource RN usually has a patient assignment or has to observe the telemetry monitors and is not as available to help on the floor. She said sometimes the unit has two Patient Care Assistants (PCA) with a full census and it is difficult for RNs to turn or reposition patients for wound care. She said nursing staff have not received formalized wound training. She said it is difficult to capture images of patient wounds as the unit does not have a working camera.

During an interview with the Director of Nursing on 1/14/25 at 2:22 P.M., she said she plans the RN/nursing staff schedules two months ahead for staffing the inpatient units. She said there is not enough RNs to staff the inpatient units for a full census of patients. She said she follows up and provided 1:1 education with the RN's when in-house acquired pressure injuries are identified on patients.

During an interview on 1/15/25 at 7:52 A.M., Wound RN #1 said if a wound is identified within 24 hours of admission, the RN should document it on the skin assessment, obtain orders for treatment or to cover the wound, and order a wound consultation. She said the Braden assessment in a patient's EMR should trigger the 4 eyes on floor assessment, which is the initial assessment completed by nursing staff to capture any wounds during the patient's head-to-toe assessment. She said identifying wounds and potential areas of skin breakdown on admission will help institute measures to treat wounds and prevent further skin breakdown for patients sooner.

During an interview with the Chief Nursing Officer (CNO) on 1/15/25 at 8:00 A.M., she said the Hospital has been unable to meet the proposed/contracted staffing grids for RN staffing on inpatient units despite offering bonuses for shift pick-ups and using contracted travel nursing staff. She said this is due to multiple staff calling out just prior to their shifts, nursing staff leaving the hospital for multiple reasons, and approved leave of absences.

The Hospital failed to ensure Patient #11's skin was assessed by nursing staff in order to prevent skin breakdown and the development/decompensation of wounds.

Based on interviews, documents reviewed, and records reviewed, the Hospital failed to ensure nursing staff followed policies and procedures for the care of two Patients (1 and #3) out of a total sample 21 patients. 1.) Patient #1 did not receive Continuous venom-venous hemodialysis (CVVHD) for fluid removal as ordered, received Hemodialysis (HD) outside of Hospital policy timeframes, and was not able to receive his/her full HD treatment for fluid removal. 2.) Patient #3 was not monitored by a RN during transport from the Emergency Department to the telemetry unit nor was a nurse-to-nurse hand-off completed as required by Hospital policy upon the Patient's transfer; Patient #3 was discovered to have decreased respirations and low heart rate for an unknown period of time.

Findings included:

1.) Review of the Hospital Policy titled "Patient Assignment within the ICU", dated 11/11/21, indicated the following:
-The ICU acuity tool is used as a guide by the registered nurse (RN), in consultation with the appropriate nursing leaders of the ICU/Hospital, to assist in determining the appropriate patient assignment upon admission/transfer into the ICU as well as during each shift.
-The patient assignment is determined by the overall acuity of the patient including both physical needs, environmental factors, and psycho-social needs of the patient.

Review of the Hospital Policy titled "Medication Management - Administration", dated 8/29/23, indicated the following:
-Administration of (drugs and biologicals) shall occur at the appropriate time as set forth by this policy and/or the medication order itself.
-The appropriate timing of medication administration must take into account the needs of the Patient's receiving them.

Review of the Hospital Policy titled "Safety Event Management" effective 12/3/21, indicated the following:

Purpose- support a culture of shared accountability for the identification, reporting and management of safety events that may impact the quality of care provided at facilities.

Definitions-

Event Report: A confidential, internal submission used for reporting of patient safety issues and performance improvement initiatives.

Patient Safety Event Reporting System (ERS): The mechanism for a Facility staff member to complete an Event Report for patient safety events or near misses.

Root Cause Analysis (RCA): A process for identifying the base or contributing causal factors that underlie variations in performance associated with SSE, SE or Near Misses.

Safety Event: Any event that leads to or is the precursor to a potential or actual negative patient outcome including a near miss, SSE, or SE

Sentinel Event (SE)- patient safety event not primarily related to the natural course of illness or underlying condition that reaches a patient and results in death, severe harm, or permanent harm.

Serious Safety Events (SSE)- Never events

Policy: Staff members who discover or who have direct involvement in and/or knowledge of a safety event must complete an Event Reports using the Facility ' s ERS. Any possible SSE and SE

Review of the Hospital contract titled "In Hospital Dialysis Services Agreement", dated 7/18/22 and amended 8/13/24, indicated the following:
- Outside of Regular Business Hours, PROVIDER shall use good faith, reasonable efforts to arrive at HOSPITAL within 4 hours of notice that emergency hemodialysis, as indicated by at least one of the following criteria (each, a "Hemodialysis Emergency"), is required: An Approved Physician indicates that for medical reasons, treatment initiation may not be delayed until Regular Business Hours.

Patient #1 was admitted to the Hospital for telemetry on 9/23/24 with a complaint of chest pain and was discovered to be experiencing NSTEMI, acute pancreatitis, and hepatic encephalopathy secondary to cirrhosis and transferred to the ICU on 9/26/24. On 9/28/24, Patient #1 underwent cardiac catheterization for coronary stent placement, suffered respiratory failure and septic shock during the procedure, was intubated and sedated, continued on norepinephrine and vasopressin for pressor support for hemodynamic instability, and had an aortic balloon pump placed. Patient #1 was transferred back to the ICU.

Review of Patient #1's medical record indicated on 9/29/24 at 7:58 A.M., Nephrologist #1 ordered Continuous Veno-venous hemodialysis (CVVHD) for Patient #1 secondary to the Patient's oliguria (not producing urine) acute kidney injury (AKI), worsening fluid volume status, and hyponatremia (low sodium levels) and hyperphosphatemia (high phosphorus levels) from his/her ability to clear fluids due to the AKI. Nephrologist #1 ordered CVVHD instead of Hemodialysis (HD) for Patient #1 as he/she would have an inability to tolerate the more aggressive ultrafiltration (removal of fluid from blood) of HD. Nephrologist #1 ordered Patient #1 to receive HD at 12:38 P.M. Patient #1 was ordered for a third pressor medication (Epinephrine intravenously (IV) 1mcg/min) at 3:51 P.M. on 9/29/24. HD was initiated on Patient #1 at 5:38 P.M. on 9/29/24 with a target fluid removal of 2400ml (milliliters). Patient #1 required epinephrine to be administered at 7:49 P.M.; the Patient's HD ended at 8:11 P.M. on 9/29/24 with a net fluid removal of 1800ml. Patient #1 required an increase in his/her norepinephrine rate as well during the HD. Patient #1's HD was stopped early as there was an emergency with another patient. On 9/30/24 at 2:00 A.M., Patient #1 became hypotensive and required max dosing on norepinephrine as well as epinephrine. On 9/30/24 at 6:00 A.M., Patient #1 required the addition of another pressor medication (phenylephrine) as his/her blood pressure was dropping. Patient #1 was transitioned to comfort measures only and expired on 9/30/24.

Further review of Patient #1's medical record failed to indicate the CVVHD was ever initiated/administered for the Patient.

During an interview with RN #12 on 1/9/25 at 9:37 A.M., she said she has never had to care for more than two patients in the ICU at the Hospital. She said typically the resource RN is able to be free from a patient assignment during the day shift, but often on night shift or weekends will need to take a patient assignment. She said there is an acuity tool available to help make the RN assignments based on patient acuity, but it is not used as often as it should be.

During an interview with RN #11 on 1/9/25 at 9:50 A.M., she said there is an acuity tool for the charge nurse to use in the ICU when making the assignments for the RNs. She said it's not typically used, most of the charge nurses know the criteria from the tool and make the ICU assignments based on those criteria.

During an interview with RN #10 on 1/9/25 at 3:16 P.M., she said she took over Patient #1's care in the ICU on 9/29/24 for the 7:00 P.M. to 7:00 A.M. shift. She said Patient #1 had been ordered to receive CVVH on the morning of 9/29/24, but was never initiated for the Patient. She said when she began her shift on 9/29/24, Patient #1 was receiving HD from the dialysis nurse. She said not every nurse in the ICU is trained to administer CVVHD for patients. She said CVVHD requires a RN to care for a patient 1:1 while administering the dialysate and treatment. She said on 9/29/24, Patient #1 did not receive CVVHD as ordered because there were not enough RNs to allow for one RN to take the Patient 1:1 while administering the CVVHD. She was unaware of any follow up after Patient #1's missed CVVH.

During an interview with RN #1 on 1/10/25 at 9:40 A.M., she said CVVH is used for patients who are critically ill with renal failure and AKIs. She said CVVHD is used to pull fluid off patients in a more gradual manner and ICU RNs can perform CVVHD but must have been trained to do it. She said patients receiving CVVHD require 1:1 care from the RN performing the CVVHD. She said often there may be patients in the ICU requiring 1:1 care but due to the unit's census and RNs available, often the RNs caring for those patients have a two-patient assignment. She said she believed another nurse not on the schedule was available to come in but was not called due to money. She said there is an acuity tool that the charge fills out for the next shift to determine the needs for the ICU patients. She said the charge RN often ends up taking an assignment and this is not always done.

During an interview with Nephrologist #1 on 1/13/25 at 8:55 A.M., he said he ordered the CVVHD for Patient #1 on the morning of 9/29/24. He said he was told the nursing staff could not initiate the CVVHD at that time and were working on getting another RN in. He said typically in the ICU when something is ordered, the patients are critically ill, and most interventions should be implemented immediately. He said he kept the order in place for the CVVHD as the nursing staff were working on bringing another RN in. He said the CVVHD was a better treatment for Patient #1 than HD because the fluid removal would have been more gradual and HD can cause rapid blood pressure issues in patients who are hemodynamically unstable. He said later in the day on 9/29/24 he was informed the Hospital could not get another RN in to work the ICU and ordered HD for Patient #1 instead of the CVVHD. He said once he orders and calls in HD for a patient, the dialysis nurse is supposed to arrive and start HD within 4 hours.

During an interview with the ICU Physician on 1/13/25 at 11:15 A.M., he said the nephrologist typically orders treatments such as CVVHD for ICU patients and will run the treatment by the ICU team. He said on 12/29/24, there was not sufficient support in the ICU RN staffing to perform CVVHD for Patients as CVVHD requires a RN to care for a patient 1:1. He said therapies like CVVHD should be started right away for critical patients, such as hemodynamically unstable patients requiring pressor medications to maintain adequate blood pressures; he said CVVHD requires availability of a RN and it can take time just to set up the perform the CVVHD.

During an interview with the Critical Care Director on 1/13/25 at 11:25 A.M., she said CVVHD would be treated with same consideration/urgency as a medication/biological order. She said on 9/29/24 she was not aware of patients in the ICU requiring CVVHD. She said she had been trying to find RN coverage for the night shift for 9/29/24 for the ICU because the charge nurse would have a full assignment, but was unable to get RNs in due to not having approval for a shift pick up bonus. She said the acuity tool is available to the ICU RNs, and according to that tool a patient receiving CVVHD would be high priority and require 1:1 care.

During an interview with the Chief Nursing Officer (CNO) on 1/15/25 at 8:00 A.M., Patient #1's care on 9/29/24 had not been brought forward as a concern nor was an incident report created for the missed CVVH for the Patient. She said on 9/29/24 the schedule had been adequately staffed for the ICU for that day and RN staffing was complicated by a RN call out on that day and an error in scheduling. She said the ICU staff need to utilize the acuity tool in order to triage patient needs in the ICU.

Review of the Hospital's acuity tool indicated a patient requiring Continuous Renal Replacement Therapy (CVVHD) and having and intra-aortic balloon pump unstable with 2 vasoactive drips would fall in the extreme risk category and a stable patient with those criteria would fall in the high-risk category, both requiring 1:1 care in the ICU.

The Hospital failed to provide an acuity tool for Patient #1 for 9/29/24.

The Hospital failed to ensure treatment was provided as ordered for Patient #1, who was intubated, sedated, and critically ill in the ICU.




40928

2.) Review of the Hospital Policy titled 'SVH ADM PC REL 9.1.54 Communication Hand-Off', reviewed 4/9/21, indicated:
-Hand off communication must occur when there is a transfer of patient care responsibility from one provider to another.
-A "hand-off" is defined as the provision of verbal and/or written information from one healthcare provider to another to ensure that the actual and potential care, service and treatment needs of the patient are effectively communicated to the next provider.
-Hand-off communication will occur under the following circumstances: transferring a patient from one internal level of care to another, including admissions from the ED.
-Hand offs can be verbal and/or written. In cases where report or patient information is written, the receiving caregiver shall have the ability to contact the sending party by phone to provide an opportunity for questions or clarification as needed.
-The hand-off communication should address pertinent up to date information regarding the patient's treatment, care and services, as well as current condition and any recent or anticipated changes, including infections.
-The elements of effective communication are situational but will reflect up to date and accurate information to allow for a safe and effective transition from one caregiver to another.

Review of Hospital policy titled 'SVH ADM CLN 8.6.8 Cardiac Monitoring- Inpatient Critical and Acute Care', reviewed 4/8/21 indicated:
-Cardiac monitoring refers to both hard wired monitoring capability and wireless ambulatory capability. Telemetry monitoring refers to a form of cardiac monitoring using a wireless transmitter for ambulatory monitoring.
-All patients on cardiac monitoring are transported without a monitor unless determined by a physician/provider.
-All critical care patients (ICU, PCU, Cath Lab, ED, PACU) are monitored during transport.
Nursing Responsibilities:
-Handoff of patients includes a review of alarm settings and rhythm.

Patient #3 arrived at the Hospital on 10/19/24 via ambulance after acute onset of vomiting coffee-ground, black emesis at home that morning.

Review of the Admission History and Physical note dated 10/19/24 at 6:12 P.M., indicated that Patient #3 was seen by the Emergency Department (ED) provider with a plan to admit the patient to the Hospital to observation with telemetry for further workup and treatment of coffee-ground emesis with concerns for upper gastrointestinal (GI) bleed (bleeding in the upper digestive tract).

On 10/19/24 at 4:49 P.M., the provider ordered Telemetry Class I (72 hours) with instructions to maintain telemetry when patient off unit.

Review of ED Patient Depart Summary indicated Patient #3 was discharged from the ED to the telemetry unit on 10/20/24 at 7:51 A.M.

Review of Nursing Narrative Note dated 10/20/24 at 9:21 P.M. indicated that Patient #3 arrived to the floor from the ED just after 8:00 A.M., and that Registered Nurse (RN) #3 noted decreased respirations, agonal breathing and a heart rate in the 30's. Patient #3 was not responsive to sternal rub and a Rapid Response was activated. The Note indicated that Patient #3 was a Do Not Resuscitate/ Do Not Intubate (DNR/DNI) and his/her family was notified of his/her condition. The Note further indicated that Patient #3 expired on 10/20/24 at 9:19 A.M. with RN #3 present at bedside.

During an interview on 1/9/25 at 9:30 A.M., RN#3 said that Patient #3 came to the unit from the ED in October. RN #3 said report is supposed to be given by the ED nurse to the floor nurse and this did not happen for Patient #3. RN #3 said she got a brief message on a beeper that Patient #3 was coming up with shortness of breath and that was the full report received. RN #3 said she was in the middle of getting shift report when she was notified that Patient #3 arrived at the floor. RN #3 said that transport had left Patient #3 in the hallway. RN #3 said she went to assess Patient #3, as soon as she was notified of his/her arrival to the unit. RN #3 said she observed the Patient was having agonal breathing and immediately brought her to a room and put him/her in the bed. RN #3 said she observed Patient #3's respirations were 6-8 breaths/ minute (normal range is 12-20/min) and that Patient #3 had dried blood all over his/her face. RN #3 said she called a Rapid Response (a system where a team of providers is summoned to the bedside when a patient is showing signs of clinical deterioration) because she did not know the Patient's code wishes and when staff responded she was informed the Patient was a DNR/ DNI. RN #3 said Patient #3 arrived to the unit without telemetry monitoring as ordered, that no RN had accompanied Patient #3 during transport to monitor the Patient and that no RN to RN report or handoff had occurred at the time of transfer. RN #3 said ED patients on monitors or certain drips are supposed to be accompanied by a nurse and this rarely happens. RN #3 said she couldn't remember if she had reported this incident via the Hospitals internal event reporting system, but didn't think she did.

During an interview on 1/14/25 at 10:13 A.M. with RN #4 and the ED Nurse Director, the ED Nurse Director said that if a patient is ordered for Telemetry 1, with special instructions to maintain telemetry while off the unit, the patient needs to remain on telemetry at all times and that an RN needs to accompany the patient between units and the patient can't be sent with a transporter. RN #4 said that if a patient is not accompanied by a nurse during transfers no report is given and said that the receiving RN would be aware of the patient's basic information such as name, DOB, room being admitted to and admitting diagnosis by the bed management team. RN #4 was unable to say why Patient #3 was not monitored by a nurse while being transferred to the unit and was unable to say why report was not provided.

The Hospital failed to ensure Patient #3 remained on telemetry monitoring as ordered, was monitored during transfer between units in accordance with provider orders and policy, and failed to ensure handoff communication was performed. Patient #3 arrived to the unit from the ED, was discovered to have agonal breathing with decreased respirations and a low heart rate and subsequently expired; the Hospital failed to ensure this event was reported by staff and investigated per Hospital policy.